Creating the Nightingale Initiative for Global Health: theoretical reflections to follow in Florence Nightingale’s footsteps

Objective: this paper articulates how three Nightingale scholars applied their theoretical reflections to Florence Nightingale’s farreaching anticipation of the year 1999 and to her comprehensive definition of “Health” derived from her 1893 essay “Sick-nursing and Health-nursing.” Method: this is a historical narrative paper. With intentions to explore how Nightingale’s insights might inform today’s nursing culture and enhance nursing practice, these scholars joined a team of civil society activists to craft the Nightingale Declaration for A Healthy World as the founding credo of the Nightingale Initiative for Global Health. To follow in Nightingale’s footsteps for more than two decades, these scholars since developed methods to increase public awareness of global health concerns and to engage today’s nurses and concerned citizens in this public advocacy. Results: project demonstration results include specific advocacy for the United Nations Millennium Development Goals and Sustainable Development Goals — “Global Goals” targeted to achieve universal outcomes specific to “Health” and across the wider scope of social and environmental health determinants — all anticipated by Nightingale throughout her 40-year career. Conclusion: given today’s severe global health concerns, these scholars’ theoretical reflections identify challenges to contemporary nursing culture — calling for methods developed to strengthen nursing’s voice in the global public arena.


Introduction
Upon completion of this historical narrative study, the COVID-19 global pandemic continues to rage across the world, with more than forty-two million confirmed cases and 1,147,301 recorded deaths (1) .
This COVID catastrophe lays bare the underlying reality that critical health needs exist everywhere -in every region, every country and every community. We all face common health imperatives. With the globalization of disease, global warming and widespread attention to equity and social justice for all peoples, healthcare is increasingly more complex and demanding in every part of the world (2) . These concerns are in keeping with a growing priority for global health -and for the related health determinants directly impacting upon health -beyond national borders and cultural margins. All these matters call for a shift in consciousness among all health professional practitioners, including students, educators, clinicians and policy makers (3) .
In a "letter to a young activist during troubled times", Dr. Clarissa Pinkola-Estés shares that, "The light of the soul throws sparks, can send up flares, builds signal fires… causes proper matters to catch fire. To display the lantern of soul in shadowy times like these -to be fierce and to show mercy toward others, both -are acts of immense bravery and greatest necessity" (4) .

Indeed, a significant example of Pinkola-Estés'
observation is the life of Florence Nightingale (1820Nightingale ( -1910, who was famously called the "lady with the lamp" during the Crimean War (1854-1856) (5) . Because of her own "fierce mercy toward others", Nightingale is renown for holding her lighted lantern high for wounded and dying British and Turkish soldiers to see -during her nightly nursing rounds to care for their severe suffering.
After returning home from those "shadowy times", Nightingale continued, for four decades, to work on the global challenges of her time -challenges remarkably similar to our own "shadowy times" (4,6) . While Nightingale is widely appreciated as the philosophical founder of modern nursing and as an early nursing theorist, she was also one of history's most accomplished reformers in health and medicine, as well as for a wider range of spheres now called health determinants (5,7) .
Anticipating today's interconnected health concerns, Nightingale called for and acted upon better conditions for women and children and for poor and marginalized people. She worked on issues now identified as environmental health determinants -like clean air and sanitation -and social health determinants -like education, employment and family relationships and culture (8) . Nightingale foresaw complex global challenges -anticipating the eight United Nations Millennium Development Goals -often called MDGs (9) that were later upgraded to become 17 United Nations Sustainable Development Goals -also named SDGs (7,10) .
As a strong global advocate, Nightingale was a change agent who challenged indifference and apathy (11) . She defined the concept of "Health-Nursing" with her own activities -noting that "Health is not only to be well, but to use well every power we have" (12) .
Anticipating our generation, Nightingale wrote a timeless challenge in her 1873 article for a popular magazine: "What will the world be on August 11, 1999 (6) . They discussed Nightingale's continuing relevance to today and began to identify innovative methods to "follow in her footsteps" into the 21 st century (6,14) . -how today's nursing culture could encompass this comprehensive Nightingale legacy (12)(13)(14)(15)(16)(17)(18) . They asked themselves, can Nightingale's voice be heard for our time?
While Nightingale had long been respected and loved, worldwide (18) , they also knew -as Nightingale scholars -that the full depth and breadth of her work had not yet been widely appreciated. For example, Nightingale effectively used two interrelated strategies.
She established her own worldwide network of friends concerned with health and then created a collaborative communications outreach to influence public opinion (18) .
Evidence of these strategies include Nightingale's 14,000 letters, 200-plus official reports and books, magazine articles, letters-to-the editor and essays -all still existing today in text collections established in many places, worldwide (19) . Nightingale used these networking and media tools of her time to stimulate action for needed changes at local, national and global levels (7) .
These three Nightingale scholars met again, in 2003, even as the SARS epidemic raged across the world -similar to today's COVID-19 pandemic (20) .
In autumn of that year, SARS had spread to Toronto, already killing many -including patients and nurses at a downtown hospital (21) . This outbreak was occurring just as Barbara Dossey, Louise Selanders and Deva-Marie Nightingale's vision and to further develop innovative methods that nurses and concerned citizens might similarly implement, in our time (6) . "We, the nurses and concerned citizens of the global community, hereby dedicate ourselves to achieve a healthy world.
We declare our willingness to unite in a program of action, to share information and solutions and to improve health conditions for all humanity -locally, nationally and globally.
We further resolve to adopt personal practices and to implement public policies in our communities and nations -making this goal achievable and inevitable, beginning today in our lives, in the life of our nations and in the world at large." for the achievement of a healthy world, together, and each in their own way (6) . Over time, this Declaration became a method for engaging online commitments of more than 22,000 nurses, midwives, and concerned citizens from 106 nations. 1,000 of these leaders signed on behalf of nursing groups totalling more than three million people (6) .
Responding to all of this global interest and activity, the authors of the Nightingale Declaration thus created and developed the Nightingale Initiative for Global Health -also called NIGH -to support and encourage the commitments embedded in this document (25) . In keeping with Nightingale's interrelated strategies for "Health Nursing", as above, their methods became NIGH's twin mandates: to promote global health issues through education and broad public communication worldwide; and to inform, empower and engage nurses and concerned citizens in this global advocacy -our common cause for achieving a healthy world (11) .

Results
Applying these mandates over many years, NIGH partnerships -all are key factors to impact upon the health of humanity, vital as health determinants (33) .
Across these same years, NIGH teams focused on preparing for a related global nursing celebration -to remember the 2010 Centennial of Florence Nightingale's death in 1910 (5) . In early consultations with like-minded nursing organizations, their founding team worked to However, this strategy was no longer popular at the United Nations General Assembly -where such a Resolution could have been officially named. NIGH was advised that this approach -to create United Nations Resolutions to remember special years -had become overused during numerous previous General Assembly sessions (6) . commended NIGH's work to motivate nurses to increase public concern for global health issues. But -to build on what was already being achieved -he recommended "turning the tables" (6) . Instead of asking the United

Nations to honour nurses with a specific General Assembly
Resolution naming a 2010 International Year of the Nurse, he invited NIGH to encourage nurses and midwives to take a global lead in helping the United Nations to increase public awareness for achieving the Millennium Development Goals. This included the one MDG identified as most-likely challenged to meet its specific targets -MDG #5 "Improve Maternal Health" (35) . Nikhil Seth Development Goals. This common cause became a firsttime strategy for nurses to join in raising public awareness to champion such United Nations "Global Goals" (6) .
In fulfilling this strategy, they also collaborated with Nursing Spectrum and NurseWeek -from the Gannett Group of publishers -to bring related media coverage to 750,000 readers (36) . As a result, they co-sponsored

For this commemoration, nurses and leaders, from North
America and across the world, filled the Cathedral to overflowing. This event was animated by opening and closing ceremonies featuring eight large banners -each to represent one United Nations MDG logo -carried high above the center-aisle by a processional of nursing dignitaries (6,37) .

While such celebrations of the 2010 International
Year of the Nurse resulted in appreciation worldwideparticularly within nurses' ranks -it also became clear that key Millennium Development Goals would still require much advocacy work -to champion the needs of billions of people, still at risk (6) .
This included the one "Goal" most specific to nursing and midwifery, "To Improve Maternal Health" -MDG #5. With more than 830 women and girls dying from pregnancy and childbirth each day, one mother perishes, on average, every 1.75 minutes -totalling a shocking 330,000 each year (38) . Anticipating the timeless relevance of MDG #5, Florence Nightingale wrote, "Upon womenkind, the national health, as far as the household goes, depends" (12) .
As a result of this understanding, they specifically advocated to achieve MDG #5 by establishing a Daring, Caring & Sharing to Save Mothers' Lives public education campaign (6) . This strategy engaged nurses and midwives to "dare, care and share" their stories. This was an aim to reverse a prevalent apathy about maternal death and to champion the needs and deeds of those nurses and midwives who struggle to make a difference for maternal health, worldwide. With an on-site launch in New York City -and then through online postings and social media outreach over 24 months -this campaign gained considerable attention with computer analytics totalled 3.5 million recorded hits from more than 90,000 unique online visitors from 146 nations (6,39) .
Another interdisciplinary project to "Improve Maternal Health" involved collaborative NIGH teams associated with the University of Cincinnati (UC), with "NM Sadguru" -an NGO based in India -teamed with the Nursing www.eerp.usp.br/rlae 6 Rev. Latino-Am. Enfermagem 2021;29:e3430.

Department of the Hinduja National Hospital and Medical
Research Centre in Mumbai, India. Across several months, UC engineering students collected data about toxic nitrate levels in drinking water and taught Hinduja staff nurses how to continue this testing. Meanwhile, these nurses also counseled pregnant mothers to strengthen maternal and infant health in that region (7,40) .
In 2013-2014, another NIGH team member, Dr. Holly Shaw, achieved results by serving for two elected terms on the United Nations "DPI-NGO" Executive Committee in New York City (41) and by leading a team of young nurses serving as United Nations "NGO Youth Reps" who participated at official United Nations Conferences during that time (6) . This team also collaborated to advance the United Nations campaign called The World We Want (42) an official survey to help determine the new Sustainable Development Goals -SDGs (43) .
To participate in this survey and encourage other nurses to do the same, their team developed and shared an online Global Briefing (44) that provided continuing education credits for American nurses. They also cohosted related workshops and conference presentations in North America and Asia (6) .
In 2015, the new Sustainable Development Goals were adopted by the United Nations General Assembly -as an overarching 2030 Agenda for Sustainable Development (45) -to establish next steps based on lessons learned from work to achieve the Millennium Development Goals (46) . Also known as the "Global Goals" and nicknamed the SDGs, the Sustainable Development Goals (Figure 3) are a set of 17 comprehensive aims -a universal call to achieve all requirements needed for a peaceful, prosperous and healthy world (9) . These SDGs are now widely considered as a blueprint for addressing the interrelated challenges we face -as a humanityincluding poverty, famine, disease, illiteracy, inequality, climate change and environmental degradation, as well as critical disruptions in both peace and justice (10) .
Used with guidelines from https://www.un.org/sustainabledevelopment/news/communications-material/ Nightingale achieved for health in her time and to the social and environmental health determinants she also addressed (8) . For instance, in 1879, while effectively advocating for the health of the peoples of India, she expressed concern for that region's climate changespecifically named in SDG #13 (10) . She wrote, "We are so stupid, so like children: we go on cutting down wood without replacing it, and for [a] great part of the year the heavens become as brass during the dry season….Then the rain, which is sure to come, destroys everything….
Scarcity is but one of the death causes in famine times.
Plants die, animals die and men die. But it is not all from want of food. Tree planting would do much both to bring rainfall and to arrest floods" (47) . In another example, from 1864, Nightingale anonymously drafted the British government's official text submitted to craft the First Geneva Convention (8) . This far-sighted international treaty social justice anticipated SDG #16, to "provide access to justice for all and build effective, accountable and inclusive institutions at all levels" (10) .
Nightingale's comprehensive work -to anticipate the Sustainable Development Goals -has set a pattern still keenly relevant for nurses today (49) . As such, these SDGs Economic & Social Council in 2018 -to further gather grassroots knowledge to be shared at global levels (56) . This Consultative Status can provide growing team of nurses and concerned citizens with unique opportunities to reflect the voices of people working to achieve health advocacy worldwide. Yet, this long-sought result is an opportunity with a distinct challenge. Nursing's public voice is yet to be fully developed, appreciated and supported (57) .

Discussion
With an increased understanding of nursing's role to advocate for achieving the Sustainable Development Goals as health determinants, we are all witnessing a shift in conscious awareness within nursing culture worldwide.
Nurses now have the potential to make vital contributions -across many settings -to address this United Nations 2030 Agenda for Sustainable Development (58) . Indeed, nurses are essential to this global effort! As demonstrated by the Nightingale Initiative for Global Health, nurses can also see ourselves as global citizens (59) . This global citizen role does not necessarily mean that we travel far from our country of origin.
Instead, we can participate in a shift in consciousness to see nursing as globally inclusive -with voices that are valued and required for the sake of humanity's health and survival (57) . While caring for patients, families and communities from this perspective, global citizen nurses are engaged with people across nations and beyond borders (41) .
Nurses are also emerging with an updated awareness of our contract with society -both in our communities and on a global scale. Following Nightingale's prediction about the year 1999, as above, we can ask a similar question.
What will our work be in 2030? Will we help to usher in an epoch of working together to live as global citizenswith a shift in consciousness to fulfill the Global Goals of achieving healthy people living on a healthy planet (60) ?
Nurses are consistently acknowledged as the most trusted and well-respected profession in the world (61) . But -despite increased appreciation for the service nurses have brought to the global 2020 COVID-19 crisis (62)the multiple roles nurses play in society are still not yet well-known, or widely understood. Though we have long assumed our roles in advocacy for our patients, our public voice -related to both nursing and health -has yet to heard from within nursing's traditional agenda (63) . The power of advocacy for health has not yet fully evolved into nursing's capacity to voice our concerns in public.
Yet, our voices have great potential to impact upon the health of humanity (57) .
We have always communicated well with each other -about our patients, our concerns, our commitments to society. We know why and how these issues matter.
Like Nightingale, we have been excellent activists at the bedside of the suffering and for the promotion of health in local community settings. But now, we also can discover -like Nightingale did -how to create our own shifts in consciousness -to evolve nursing activism into global public advocacy, providing nurses with new levels of effective participation and influence (57) . One of the ways to continue this work would be to return to the original Nightingale Declaration for A Healthy World -with a plan to make an updated version available online, in the six official United Nations languages and many more (23) . The opening line, "We the nurses and concerned citizens of the global community", re-affirms our collective commitments to our ongoing work -just as Nightingale did in her time. With "our willingness to unite in a program of action, to share information and solutions and improve health conditions for all humanity", nurses and concerned citizens can further develop our capacity to share our voices, and feature stories online and across traditional media.
While the forward challenges ahead seem daunting, Clarissa Pinkola-Estés continues her words of encouragement to all nurses and concerned citizens. "It is not given to us to know which acts or by whom, will cause the critical mass to tip toward an enduring good.
What is needed for dramatic change is an accumulation of acts -adding, adding to, adding more, continuing. We know that it does not take 'everyone on Earth'….but only a small, determined group who will not give up during the first, second, or hundredth gale.…One of the most calming and powerful actions you can do to intervene in a stormy world is to stand up and show your soul. Soul on deck shines like gold in dark times (4)" .
As nurses make our own shifts -to expand our caring consciousness and reconnect with a renewed sense of "calling" in nursing -we can relight our own lamps and carry Nightingale's vision of caring, healing and leading -with an expanded awareness that everything we do impacts health and healing everywhere (7) . This is a fitting development, because the word "nurse" is derived from the Latin nutrire, meaning "nourish". It is the nurses -with exemplary empathy, compassion, caring, and wisdom -who nourish countless humans in their journeys from birth to death (28)(29)(30)65) . In Nightingale's last major essay, she again sends her own voice ahead, into our time. "May we hope that, when we are all dead and gone, leaders will arise who have personally experienced….the difficulties and the joys and who will lead far beyond anything we have done (12)" .

Conclusion
As nurses reflect upon Nightingale's vision for our generation, we can appreciate how her wisdom resides within each of us and can still guide us. Her example is a source of power from the past, through which we can find our vision and strength -to assert ourselves at this very challenging moment in history -and to impact upon future nursing generations. Nightingale planted seeds for us -seeds that have germinated and flowered into the magnificent "calling" and profession known as nursing today.
As a nurse and an early global citizen, Florence Nightingale established an unprecedented approach to becoming an effective, awesome human being who helped to shape a better world. As she demonstrated in her time, we -the nurses of today -stand at the vanguard of what humanity can yet become. How would Nightingale advise us? Can we hear her voice? Can we, indeed, follow in her footsteps toward achieving a healthy world?